Provider Appeals Resources

Overview

Providers, individuals, or entities that have a contract with DMAS to provide services may appeal any DMAS action subject to appeal under the applicable laws and regulations, including issues related to reimbursement for covered services, DMAS's interpretation and application of payment methodologies and provider enrollment. As part of the appeal process, an impartial representative will conduct a review to determine whether the action proposed or taken was correct. The end result of the appeal is a written decision. Formal appeal decisions by the DMAS Director may be appealed to court for review of the record.

How to Request an Appeal

In 2025, the General Assembly directed DMAS to promulgate regulations to require providers to file their appeals online.  DMAS has started the process of updating its regulations.  We encourage all providers to consider using the Appeals Information Management System (“AIMS”) now in order to more easily file their appeal, upload documents, and track the status of the case.  The online process is fast, efficient, and immediately assigns a case number.  We anticipate that the regulations to require filing in AIMS will be finalized in 2026 and urge providers to get accustomed to AIMS prior to it being the only method of filing appeals. 

The following methods remain available to file appeals until the update to the regulations is complete: 
      1. Use the AIMS portal. The portal is located here.
      2. Email the appeal request to appeals@dmas.virginia.gov. 
      3. Fax the appeal request to DMAS at (804) 452-5454. 
      4. Mail or bring the appeal request to: 
          Appeals Division
          Department of Medical Assistance Services
          600 E. Broad Street
          Richmond, VA 23219

Please refer to Chapter II of the DMAS Provider Manuals for additional appeal request requirements. The Appeals Division will only process provider appeal requests that meet these requirements. 

 

Please note: Providers who have received a claim (payment) denial from DMAS may wish to submit a new claim that includes corrections on the claim instead of filing an appeal. If you are unclear about why the claim was denied, DMAS encourages you to contact the Provider Helpline at (800) 552-8627 before deciding whether to file an appeal. If an appeal is filed, it will only address the denial reason(s) set forth on the remittance advice. Filing an appeal does not correct the denial reason(s) nor does an appeal involve reprocessing claims. If you are seeking to correct your claim, do so and resubmit your claim with the claim corrections for payment rather than filing an appeal.

Resubmitted claims will be processed as quickly as possible (usually within 30-60 days or sooner). If another denial occurs, that remittance advice will carry new appeal rights to DMAS.

Informal Provider Appeals At-A-Glance Thumbnail
[PDF] Virginia Medicaid Informal Provider Appeals: At-A-Glance

Formal Provider Appeals At-A-Glance Thumbnail
[PDF] Virginia Medicaid Formal Provider Appeals: At-A-Glance

 

Provider Appeal Resources

Provider Appeal Forms

Provider Appeal Regulations